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Online First – Evaluation of a community pharmacy delivered oral contraception service

Parsons et al.’s evaluation of a community pharmacy delivered oral contraceptive (OC) service is of particular interest, as it demonstrates the value of providing OCs via this service outlet, especially for women who would not otherwise access long-term contraception. Between 2009 and 2011, seven specially trained pharmacists at five pharmacies in South-East London provided OCs under a Patient Group Direction (PGD) during 741 client consultations. The evaluation showed that trained pharmacists were clinically competent to provide OCs according to a PGD, and that the service was successful in attracting the population identified as most in need. Nearly half of all consultations occurred following emergency hormonal contraception supply, and nearly half of clients receiving an initial supply of OCs were first-time Pill users. Based on satisfaction questionnaires from a small sub-group, most clients valued this service, were happy about privacy, and would recommend it. Although the primary aim was to reduce teenage pregnancy , and nearly a quarter of clients were aged <20 years, the study shows that women aged 20+ years also require this service and should not be overlooked when formulating policies for service provision.summary by Walli Bounds, Associate editor

Infertility: Survey shows nearly half of all GPs lack knowledge

Results of a comprehensive patient survey by the National Infertility Awareness Campaign (NIAC) shows that GPs need to be better informed about infertility treatment, including IVF, and the options available when the commissioning of IVF switches to local commissioning groups next year. The NIAC survey found that nearly 50% of GPs lacked the necessary knowledge of infertility and the treatment options available to provide an effective service. This could explain why some patients with fertility issues perceived their GPs as unsympathetic.

Calling All Baby Boomers: Get Your Hepatitis C Test

A report issued by the U.S. Centers for Disease Control and Prevention (CDC) recommended that all Americans born between 1945 and 1965 be tested for the hepatitis C virus (HCV). An estimated 2.7 million to 3.9 million people in the United States are infected with this liver-damaging—and sometimes lethal—virus, and many do not know they carry it. CDC calculates that roughly 75% of those infected are baby boomers: 3.25% of people born in that “birth cohort” test positive for HCV, which is five times higher than the rate in adults born before 1945 or after 1965. CDC has determined that universal testing of baby boomers is the most cost-effective strategy for detecting undiagnosed HCV infections. As reported in Science

New lab for HIV research

The Indian Government has opened the new $12 million HIV Vaccine Translational Research Laboratory in New Delhi. The new Laboratory will aim to recruit around 30 scientists with the goal of creating a new vaccine against HIV, and will work in collaboration with the International AIDS Vaccine Initiative. As reported in Science

More than poverty: disruptive events among women having abortions in the USA (Jones)

We are all aware that poverty is associated with abortion but how many of us knew that bad (or disruptive) life events also play a major role? The research by Jones et al. demonstrates that more than half of the women seeking abortion had experienced a disruptive life event in the preceding 12 months. Women are making decisions about their abortion whilst in the midst of complex life events. The authors’ suggestions for changes in policy may not be directly relevant in the UK; however, the study findings are of wider significance. from Gillian Robinson, Associate Editor

Psycho-social factors affect semen quality (Cao)

Semen quality appears to be declining and this cross-sectional study in China casts light upon some factors that may be associated with that decline. The research team analysed the semen of 1346 healthy 20-40-year-old Chinese men, capturing their psychological, social and behaviour profiles via questionnaire. It appears that stress, social class and underwear made from man-made fibres all play a significant part in declining semen quality. from Scott Wilkes, Associate Editor

Young people and chlamydia – peer led strategies to increase the uptake of screening (Horner)

The major burden of Chlamydia trachomatis infection is borne in individuals under 25 years of age. Complications of untreated infection are manifold and encompass pelvic inflammatory disease, sub-fertility, epididymo-orchitis, urethritis, arthritis, conjunctivitis and proctitis. Despite high hopes, uptake of the English National Chlamydia Screening Programme has been lower than expected. As a result, the expected decline in chlamydia prevalence has not been observed. Paddy Horner’s group have investigated the use of a peer-led approach to increase screening and examine the feasibility and acceptability of this strategy in young people. Interestingly, although this is a relatively small proof of principle study, women peer-led screening was more successful than male in recruiting peers to participate in the programme. from Rachael Jones, Associate Editor

Inequity in family planning provision in urban Nigeria: a providers’ perspective (Herbert)

In Nigeria contraceptive use is low: used by only 10% of married women and with 20% of women estimated to have an unmet need. Provision needs to improve, and understanding the roles and perspective of the mixed economy of contraceptive providers is a key step in designing better services. A qualitative study from the Nigerian Urban Reproductive Health Initiative explores the experiences and challenges faced by a range of providers in two urban Nigerian areas. Using structured in-depth interviews and checklists, researchers identified need for further training and support for all providers to empower them to provide a wider range of contraception. Few providers engaged in meaningful promotional activities for their products or services. Vulnerable groups, likely to have high needs for contraceptive advice and provision, were routinely excluded from family planning services: adolescents, married women and those seeking post-abortion care. Understanding the underlying reasons for this inequitable provision, and developing appropriate marketing strategies and materials will indeed be key to developing more sensitive service provision. from Imogen Stephens,Associate Editor

New female condom, the ‘Woman’s Condom’ – will the Chinese go for it? (Coffey)

The need for products that simultaneously protect against unwanted pregnancy and STIs, including HIV, has prompted interest in the development of Multipurpose Prevention Technologies (MPTs), including new variants of the female condom. In this issue, Coffey and colleagues describe their survey of initial reactions to the ‘Woman’s Condom’ (which obtained marketing approval in China in 2010) by potential user groups in Shanghai. Their study demonstrates the importance of assessing the potential acceptability of new products in a range of populations, with differing expectations, needs and culture-specific influences. Their findings are of particular value to programme/service providers, in order to identify most likely adopters of this new type of female condom. from Walli Bounds, Associate Editor

DH releases abortion statistics, England & Wales: 2011

The main findings of the newly released abortion statistics are:
• The total number of abortions was 189,931, 0.2% more than in 2010 (189,574) and 7.7% more than in 2001 (176,364).
• The age-standardised abortion rate was 17.5 per 1,000 resident women aged 15-44, the same as in 2010, but 2.3% higher than in 2001 (17.1) and more than double the rate of 8.0 recorded in 1970.
• The abortion rate was highest at 33 per 1,000 for women aged 20, the same as in 2010 and in 2001.
• The under-16 abortion rate was 3.4 per 1,000 women and the under-18 rate was 15.0 per 1,000 women, both lower than in 2010 (3.9 and 16.5 per 1,000 women respectively) and in the year 2001 (3.7 and 18.0 per 1,000 women respectively).
• 96% of abortions were funded by the NHS. Over half (61%) took place in the independent sector under NHS contract, up from 59% in 2010 and 2% in 1981.
• 91% of abortions were carried out at under 13 weeks gestation. 78% were at under 10 weeks compared to 77% in 2010 and 58% in 2001.
• Medical abortions accounted for 47% of the total, up from 43% in 2010 and 13% in 2001.
• 2,307 abortions (1%) were carried out under ground E (risk that the child would be born handicapped).

Non-residents:
• In 2011, there were 6,151 abortions for non-residents carried out in hospitals and clinics in England and Wales (6,535 in 2010). The 2011 total is the lowest in any year since 1969.

FPA reacts to the release of abortion statistics

Julia Bentley, Chief Executive, welcomed the decrease in abortions for under 16s and under 18s alongside a very small increase in the total number overall while highlighting the worrying trend in restrictions to contraceptive service provision.

New data show STI diagnoses on the rise in England

Figures released by the Health Protection Agency (HPA) show new sexually transmitted infection (STI) diagnoses rose by 2% in England in 2011, with nearly 427,000 new cases, reversing the small decline observed the previous year. Young heterosexual adults (15-24 years) and men who have sex with men (MSM) remain the groups at highest risk. More

Joint statement from FPA and Brook on STI data

In a joint statement the sexual health charities said: “This is a worrying reverse trend. It demonstrates exactly why safer sex messages and campaigns that young people and gay men will listen to and take action on, are absolutely necessary. Testing and treatment services are vital, but alone they are not enough to change people’s behaviour. The impact of the government’s disinvestment in campaigning around safer sex and sexual health reflects in today’s statistics. Yet again we see more data illustrating why there is an urgent need for statutory sex and relationships education in schools alongside sustained investment in sexual health services.”

Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according WHO. Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics – the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected with gonorrhea, which is transmitted sexually. More:

Policymakers Recommit to Unfinished Agenda of Landmark Cairo Population Conference

In Istanbul, on 25 May lawmakers from 110 countries reaffirmed their support to the principles and goals of the 1994 Cairo International Conference on Population and Development (ICPD), emphasizing their continued centrality to efforts to reduce poverty and safeguard people’s health and rights, including sexual and reproductive health and reproductive rights. Press release

Redefinition of women’s health care

Last year the Royal College of Obstetricians and Gynaecologists published ‘High Quality Women’s Health Care: a Proposal for Change’ that proposed a radical change to the structure of UK women’s health services. Andrew Horne and Johannes Bitzer discuss this exciting document from both a UK and a European perspective, commenting on its implications for sexual health provision. See page 68

Multidrug-resistant gonorrhoea

Gonorrhoea infection is increasing in the UK with a 3% increase in cases between 2009 and 2010. Last year there was a report of a ceftriaxone-resistant isolate; there is a growing concern that gonorrhoea may become incurable. The commentary by Taylor and Bignell is timely. It reviews the current position and provides clear guidelines on screening and treatment, which may prove challenging for some community services that rely exclusively on the use of nucleic acid amplification tests. See page 70

At last, a COC licensed for use in a flexible extended regimen

Data are presented from Phase III studies of a 20 µg ethinylestradiol/3 mg drospirenone combined pill, designed to be used in a flexible regimen. The studies evaluated the efficacy of the regimen, bleeding patterns, safety (ie, metabolic and endometrial parameters) and effect on dysmenorrhoea. Comparisons were with a fixed extended regimen and the conventional 24-day regimen. Results show good efficacy, tolerability and safety with the flexible regimen, and a significant reduction in both bleeding and dysmenorrhoea. See pages 73, 84, 94

Does hormone replacement therapy cause breast cancer? Part 4. The Million Women Study

Shapiro et al. continue their review of breast cancer and hormone replacement therapy papers, this time focusing on the Million Women Study. They conclude that despite its massive size, this study did not satisfy causal criteria. The online version of this paper has already been the focus of a great deal of media publicity and both a news piece and an editorial in the BMJ. Readers should also look at the Letters section for related correspondence that the Journal has received as a result. See page 102

A new aid to diagnosis

Ultrasound imaging has been of value to our specialty for over two decades and skills and equipment have steadily become more available within sexual and reproductive health clinics. In their article on hysterosonography using a local anaesthetic gel, Pillai and Shefras present their experience with a simple and effective new technique that takes imaging a step further, allowing clear diagnosis of intrauterine abnormalities, particularly causes of abnormal bleeding or failed intrauterine device/system (IUD/IUS) insertion, as well as aiding location and easier retrieval of IUDs with missing threads. Many readers will be familiar with the use of lidocaine gel to aid IUD insertion: not surprisingly, uterine instrumentation in conjunction with scanning was reported to be less painful with this technique. This is a promising approach to simplifying and improving the cost-effectiveness of care for women presenting with some complex contraception problems. See page 110

Abortion legislation in a changed world

In his latest Legal Opinion article, Sam Rowlands reviews legislation governing early medical abortion (EMA) and the licensing of EMA drugs in the UK and in other jurisdictions. He then looks at the ways in which such legislation has been used – or in some cases circumvented. EMA has helped to fulfil the crucial need for safe abortion worldwide, but in the author’s view the laws governing abortion in most countries are out of step with scientific advances. Readers may find the author’s conclusions and suggestions for future changes to our own abortion laws thought-provoking. See page 117

Role of doulas in abortion care

Doulas, or lay support persons, have had a longstanding role in supporting women in labour. Chor et al. argue that their role should be extended to caring for women having abortions, where they can help women relax and provide information. They suggest that engagement of the medical community will be instrumental in successfully expanding the role of abortion doula programmes within abortion provision. See page 123

Abortion in the classical world

Lesley Smith continues her series on the history of contraception and reproductive health with a look at attitudes to and practices of abortion in ancient times. It appears that even then, abortion was at the heart of much medical ethical debate. See page 125

Status of health professionals in the 21st century

Has the status of health professionals in society today fallen? If so, why? And is it a good or a bad thing? The Journal’s Consumer Correspondent, Susan Quilliam, explores the issue in her latest article. See page 127

Twenty-five years on: HIV remains a concern

In his latest ‘Then and Now’ article, Lindsay Edouard looks at topics covered by this Journal in 1987. New approaches to contraception were emerging. But was there a threat to community family planning services and would litigation faced by USA manufacturers restrict contraceptive choice? However, the major concern was the emergence of HIV/AIDS, with reinforcement of the advice that barriers should be used in addition to hormonal methods. In 2012, in the light of controversial research suggesting a possible association between hormonal contraception and increased HIV risk in some settings, Edouard draws our attention to the WHO very recent guidance regarding dual protection: 25 years on, advice has not changed. See page 131

Plus – Online Poll

Will the recent article on hormone replacement therapy and breast cancer alter your prescribing practice with regard to HRT?

The celebration, hosted by Nitin Ganatra (Eastenders), to mark the hard work and dedication of people involved in sexual health across the UK took place at Troxy, London. Celebrities, including Janet Ellis, Zoe Margolis, Sharon Marshall, Johnny Partridge and our own Susan Quilliam and Alison Hadley were in attendance to show support and present awards to:

Sexual health professional of the year:Kay Elmy, Peterborough Contraceptive and Sexual Health Service.JLS young person of the year: Azizi Kosoko, Terrence Higgins Trust.Rosemary Goodchild Award for excellence in sexual health journalism:Sophie Goodchild for her article ‘Free love: what happened to AIDS?’ Men’s Health magazine.Adult sexual health service/project of the year: ‘Morning-after-pill in the post’ campaign,bpas.Young people’s sexual health service/project of the year:Sheffield Open Doors, Sheffield Contraception and Sexual Health Service, School Nursing Service and the Young People’s Drug and Alcohol Service.Pamela Sheridan Award for Innovation in SRE: Shropshire Respect Yourself Relationship and Sex Education Programme.Lifetime Achievement in sexual health award presented to Professor Michael Adler CBE.

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Research highlights risks with current tests for Chlamydia trachomatis

“Researchers, from the University of Southampton and the Wellcome Trust Sanger Institute, have discovered that Chlamydia is much more diverse than was previously thought. Using whole genome sequencing, the researchers show that the exchange of DNA between different strains of Chlamydia to form new strains is much more common than expected.” Current clinical tests only give a positive or negative result and can not identify different strains. In clinical practice those found to be chlamydia positive after treatment were assumed to have been re-infected but this may not be the case. Up until now antibiotic resistance has not been seen in humans only in the laboratory but current tests would be unable to demonstrate this if it did occur.

New BASSH Patient Information Leaflets

The BASSH Clinical Effectiveness Group (CEG) has produced new patient leaflets on Safer Sex, Epididymo-orchitis and Gonorrhoea. These are available from their website along with details about up-coming events as well as news and other guidelines.

GMC seeks views on proposed changes to the way doctors are assessed for GP or specialist registration through the ‘equivalence’ or CESR/CEGPR route to registration

“This International Women’s Day, the world’s women have much to celebrate: maternal mortality rates are declining after years of stagnation; the importance of maternal health is receiving unprecedented attention; and one solution in our efforts to save women’s lives during childbirth, misoprostol, is gaining significant traction globally. But we have further to go for the world’s women.” IWD website has links to a number of events happening around the globe and asks supporters to publish and share their initiatives

fpa and Brook join forces with Durex

Two of the country’s leading sexual health charities and the biggest condom brand in the UK have announced a major collaboration with a three year programme to deliver a number of sexual health initiatives; information events, public awareness campaigns and learning materials.

Media Reaction to Abortion – gender selection and legal issues

in the ongoing debate around gender-selection abortion an Open letter of support for doctors who provide abortion services was published by Reproductive Health Matters, the international journal for sexual and reproductive health and rights, signed by members of Voice for Choice, leaders in womens’ health and abortion care. The letter clarifies many of the misinterpretations of legal issues that have been voiced in much of the ‘popular’ press.

Sexual Health Trainers – new PGA Med Ed (SRH)

The FSRH website has details of the planned changes to ‘training the trainers’. The current letter of competence (Loc MEd) will be replaced by the new Post Graduate Award in Medical Education (Sexual and Reproductive Health). In collaboration with Keele University the course is aimed at doctors working in CASH, GP’s, those in GUM and nurses who wish to gain a recognised teachers qualification in sexual health. This PGA will, for doctors, be accepted as appropriate for Primary Trainers for DFSRH purposes.

The GMC Education Update (Feb 2012) includes notification of a consultation on the recognition and approval of trainers.

The FSRH Clinical Effectiveness Unit (CEU) have published their latest clinical guidance document which updates previous guidance from 2006. Changes include: new tests for gonorrhoea and chlamydia; changes to treatments available for vulvovaginal candidiasis (VVC) & bacterial vaginosis (BV); and new advice on combined hormonal contraception (CHC) and antibiotics.

BPAS website hacked

The British Pregnancy Advisory Service website has been the subject of attempted hacking. A 27 yr old man has been arrested on suspicion of offences under the Computer Misuse Act. In a statement issued today BPAS say that:

“Around 26,000 attempts to break into our website were made over a six hour period, but the hacker was unable to access any medical or personal information relating to women who had received treatment at bpas.”

Treatment is freely available, but is limited to those who know their HIV sero-status. The HIV epidemic in the UK continues to grow, and the fraction of undiagnosed HIV remains frustratingly constant. The number of people living with HIV in the UK is estimated to be 91500 in 2010. There were an estimated 6660 new HIV diagnoses in the last year alone. In men who have sex with men, there were 3000 new diagnoses – the highest ever annual figure recorded in this risk group. An estimated one in four of all individuals with HIV infection remains unaware of their sero-status. Of those newly diagnosed, half were diagnosed with CD4 counts below 350 cells/μl, the current threshold for the initiation of antiretroviral therapy. Of the 680 people with HIV who died in 2010, two thirds had been diagnosed late.

and they suggest that:

The largest barrier rests with us, the healthcare providers: our own HIV testing prejudices need to be broken down. We need to engage commissioners to develop services and strategies to tackle HIV infection in our community. A key strength of the pilot studies to date has been the close cooperation between Sexual Health services and local primary and secondary care providers. We would urge you to work with your local Sexual Health colleagues. They will be keen to work with you to provide education, support, clinical expertise and guidance to keep this issue high on your local health agenda. Please engage with us, and Getting to Zero may be a feasible and very real vision here on our own doorstep.

This is the good news. The bad news is that at this crucial time, when the end may be in sight, we also hear that the one thing that will fuel the hoped for future is being cut off:

BMA News warns that Sexual Health is under threat (again).
As councils and private companies take control of NHS sexual health services, are they unnecessarily changing an open-access system that already works wonders?In the Report, sexual health organisations have expressed grave concerns and a number of clinicians give examples of difficulties already being experienced.

The Global fund to Fight AIDS, TB & Malaria has cut its latest round of funding. In its press release yesterday it states:

A sharply deteriorating economic situation, which is placing severe pressure on donor countries’ budgets, has prompted the Global Fund to revise its forecasts of available resources over the next two years and to take this difficult decision.

The Royal College of Obstetricians and Gynaecologists (RCOG) has, this week, published its revised guidelines on the care of women requesting induced abortion. The recommendations cover commissioning and organising services, possible side effects and complications, pre-abortion management, abortion procedures and follow up care. A summary of new and improved recommendations and link to Q&A’s are in the RCOG press release.

Medical Students for Choice (MSFC) – based in the US, is a non-profit organisation recognising the need to create abortion providers for tomorrow: www.medicalstudentsforchoice.org. They aim to try and correct the drastically falling numbers of providers in the US and Canada – 57% of current providers are over 50. This along with targeted violence, restrictive legislation and medical schools not addressing the issue means doctors are qualifying with little knowledge of abortion.

RCOG Honorary Fellowship

Toni Belfield

Our friend and colleague, Toni Belfield, has, today, been awarded an RCOG honorary fellowship in recognition of her long service in the field of contraception and sexual health and passionate dedication to providing accessible, evidence-based information for men and women. Included in the citation Professor Janice Rymer noted responses from colleagues who said Toni is “One of the most knowledgeable people in women’s health” and “Her contribution is always very sound”. Her many friends in the field know, love and respect her as an ardent advocate for service users (never patients or clients!) and as someone who always keeps us on our toes when it comes to accurate use of terminology – we always fit IUDs never coils! Congratulations Toni.

Take Action! Respond to the PSHE Review – Deadline 30th November

The Department for Education is running a Review of PSHE including Sex & Relationships Education with a view to improving its delivery in state funded schools. You can read the review and respond online by following the link. The British Humanist Association has succintly summarised the situation and the fears of many in its statement to accompany its own response.

Gardasil to be used in the UK HPV vaccination programme from September 2012

Posted by Anne Szarewski, Editor in Chief, JFPRHC

The Department of Health made the announcement this week, though it was an inevitability, since there was only one vaccine being considered. GSK had made the decision not to participate in the tender process back in September, but the DH perhaps wanted to make sure that this year’s school vaccination schedule was not derailed by parental confusion – by now most girls in this year’s programme will have had their first two vaccinations of Cervarix.

While Gardasil offers protection against genital warts, which Cervarix does not, Cervarix has been shown to give greater protection against cervical cancer, due to its much greater cross protection against non-vaccine HPV types. Indeed, this was acknowledged in the recent paper by Jit et al (BMJ 2011;343:d5775 doi: 10.1136/bmj.d5775).

However, there has been mounting pressure for protection against genital warts, so this outcome will be welcomed by many, especially our colleagues in GUM. However, if discussing the decision with parents who may be worried that their daughter was ‘given the wrong vaccine’ we can reassure them that by having Cervarix, those girls will have had the benefit of greater protection against cancer. It is a shame that one has to choose: I have long suggested that a potential solution would be to vaccinate girls with Cervarix and boys with Gardasil, which would give herd immunity against warts, offer protection to MSM and still allow girls the better cancer protection.

As Halloween and Trick or Treat approach we face an even greater horror, as Monday 31st October 2011 is the day the world’s population is forecast to crash the 7 billion barrier only 12 years after it passed 6 billion.

Despite overall rates of fertility falling and the basic right of all women to manage their own fertility having been officially recognised at the Cairo Conference in 1994, 215 million women in ‘high fertility’ countries still don’t have access to voluntary contraception. In addition “millions of adolescent girls and boys have little access to sex education and information on how to prevent pregnancies or protect themselves from HIV.” UNFPA report – The State of World Population 2011

As the number of commentators that report and respond to this prediction increases will politicians and others in power finally listen to what ‘family planners’ have been saying for years and concentrate budgets where they can do some good. Or are we in danger of ignoring this situation until it is too late. This, of course, echoes the post of 4 weeks ago that reported Mary Robinson ‘s warning to the UN on the same issue on the 20 year anniversary of the Rio summit and declaration .

UK’s Breast Screening Programme to be Reviewed

The UK’s National Cancer Director, Professor Sir Mike Richards, has ordered an independent review as questions were raised by the Nordic Cochrane Centre’s systematic review over whether screening may do more harm than good. As this controversy could undermine the excellent effects that are achieved by screening it is important to investigate and resolve any uncertainties. As Sara Hiom of Cancer Research UK (who will jointly lead the Review) said “We mustn’t lose sight of the fact that the fundamental principle underpinning screening – that earlier diagnosis helps improve outcomes – is right and that screening does help save lives”.

MHRA warns against purchasing HIV and non-compliant tests over the internet

We also hear that non-CE marked tests which claim to diagnose HIV and other STIs, available from a UK-hosted website, could give inaccurate results according to a press release from the MHRA . This is aside from the fact that it is illegal to market HIV tests to the public. The HPA has also been involved in contacting all those known to have purchased the tests but warn others considering using the internet as a way of accessing anonymous testing to check that any product is compliant with regulations.

Good News: another new study confirms what we already knew that The Pill and pregnancy have the biggest impact on reducing ovarian cancer risk – published in the British Journal of Cancer and part-funded by Cancer Research UK. The greatest protection was afforded by taking the pill for more than 10 years followed by ever users then getting pregnant and having more than one child.